Southern College of Optometry Ocular Rosacea Jason Duncan, OD, FAAO Associate Professor Southern College of Optometry

Rosacea Subtypes Erythematotelangiectatic Papulopustular Phymatous Ocular ROSCO panel recommendations Phenotype based

Global Rosacea Consensus Diagnostic phenotypes Fixed centrofacial erythema in a characteristic pattern that may periodically intensify Phymatous changes Patulous follicles Skin thickening or fibrosis Glandular hyperplasia Bulbous appearance of the nose

Global Rosacea Consensus Major phenotypes Papules and pustules Flushing Telangiectasia Hard to see in darker skin Ocular manifestations Secondary phenotypes Burning and stinging Facial edema Dry facial appearance

Etiology and Pathology of the Disease Dermal matrix degeneration Ferritin expression Reactive oxygen species VEGF overexpression Antimicrobial peptides

Ocular Rosacea What do we mean when we say Ocular Rosacea? Clinical signs Lid margin telangiectasia Conjunctival injection Marginal keratitis Scleritis and sclerokeratitis “honey crust” and collarette accumulation at lash base Lid margin irregularity Ocular surface disease

Patient Symptoms May be intermittent Usually chronic Associated with triggers Presenting symptoms Flushing Irritation Conjunctiva Lids Aesthetics Telangiectasia Periorbital lymphedema Gritty feeling/FB sensation Lid edema Burning/stinging Raw feeling

Diagnosing Ocular Rosacea May precede other cutaneous signs by years Difficult with darker skin Must exclude other diseases

Diagnosing Ocular Rosacea “You got the look” Thin skin Light hair/skin Suspect in cases of Mild conjunctivitis with no other dx Blepharitis Demodex Dry eye patients Meibomitis patients Marginal keratitis patients Look for Tylosis Lichenification Telangiectasia Face/lids Marx line Lid margin ridges Corneal opacities Pannus Marginal keratitis Collarettes Lid debris Meibomian stasis

Rosacea Triggers Temperature Wind Caffeine Exercise Spicy food Alcohol Skin products Stress Any vasodilators Hot drinks

Management of Rosacea Avoidance of triggers Vascular oriented lasers Pulsed dye laser Potassium-titanyl-phosphate laser Diode-pumped frequency doubled laser Long-pulsed Alexandrite laser Long-pulsed Nd:YAG laser Non – ablative lasers Electrosurgery Isotretinoin Intense pulsed light therapy Surgery

Management of Rosacea Medications Metronidazole Retinoids Tretinoin isoretinoin Alpha -2 agonists Brimonidine Oxymetazoline Topical ivermectin Beta blockers Fusidic acid

Management of Rosacea Medications (cont) Tacrolimus Doxycycline/minocycline Erythromycin Topical clindamycin Oral steroids

Management of Ocular Rosacea Topical Alpha adrenergic Brimonidine Steroid/antibiotic Artificial tears Lid hygiene Avoid astringents, menthols Ciclosporin Oral Beta blockers carvedilol doxycycline